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Published on 12 March 2013

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Medicines reconciliation on a medical admissions ward

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Medication errors are a leading cause of patient injury and this study demonstrates that significant time can be saved by the pharmacy team by offering medicines reconciliation at different levels depending on patient need
Linden Ashfield PGDipClinPharm MPSNI
Chris Hutchinson PGDipClinPharm MPSNI
Ida Mattsson MSc Pharmacy
Michael G Scott PhD FPSNI MCPP
Glenda F Fleming PhD MPSNI
Pharmacy and Medicines Management Centre, Northern Health and Social Care Trust, Antrim Area Hospital Site, Antrim,
Northern Ireland, UK
Email: drmichael.scott@northerntrust.hscni.net
Medication errors are a leading cause of patient injury and it has been reported that such errors may ultimately lead to patient death.(1) It is recognised that medication errors can occur at transition points in patient care, including admission to hospital, and the estimates of variation between the medications that patients are taking prior to admissions and those prescribed at admission are high (30–70%).(2) Lack of communication at transition points may be responsible for up to 50% of medication errors and up to 20% of adverse drug events in hospital.(3) In order to help prevent these problems arising, it is recommended that hospitals in the UK undertake a process of medicines reconciliation when patients are admitted.(4)
Medicines reconciliation has been defined as: ‘the process of creating and maintaining the most accurate list possible of all medications a patient is taking — including drug name, dosage, frequency, and route — and using that list to guide therapy. The goal is to provide correct medications to the patient at all transition points within the hospital. Medication reconciliation can be considered complete when each drug the patient is taking has been actively continued, discontinued, held, or modified at each transition point.’(3)
A guide to assist healthcare organisations implement medicines reconciliation processes has been developed by the National Prescribing Centre in the UK.(1) Within this guide, two stages of reconciliation are described. Basic reconciliation (stage 1) is the collection and accurate identification of a patient’s current list of medicines. The information may come from a range of sources including from the patient or the General Practitioner’s records. The information gathered is recorded and any discrepancies noted. Full medicines reconciliation (stage 2) builds on the medication history taken at stage 1 by identifying all discrepancies, resolving them and recording the outcome.
If possible, the National Institute for Health and Clinical Excellence (NICE) and the National Patient Safety Agency (NPSA) recommend that medicines reconciliation should occur within 24 hours of a patient’s admission to hospital, and there is support for the increasing involvement of pharmacists in the process.(4) Within Northern Ireland, there are a number of practical difficulties with regards to pharmacists conducting full (stage 2) medicines reconciliation within 24 hours, including limited pharmacy staff resources and current pharmacy work hours within the region.
In recognition of the limitations, the Pharmacy Senior Management Team at the Northern Health and Social Care Trust have set a target of 95% of patients receiving medicines reconciliation by a pharmacist within 48 hours of admission as an interim step to meeting the NICE/NPSA recommendations.
The current study aimed to explore if limited pharmacy resources could be better utilised in the provision of medicines reconciliation. In particular, the study team wished to determine if patient criteria could be identified that would allow medicines reconciliation to be offered at the two different levels, based on patient need. In addition, the team wished to establish if offering medicines reconciliation at two levels would save pharmacy time in the processes of medicines reconciliation, preparation of the discharge summary and dispensing of the required discharge medications
Methods
The study was carried out over a 12-week period on a 28-bed medical admission ward in Antrim Area Hospital (a 426-bed district general hospital in Northern Ireland). Data collection was carried out in three four-week time periods:
  • Time-period one – weeks one to four
  • Time-period two – weeks five to eight
  • Time-period three – weeks nine to twelve.
Patients who were discharged from hospital without pharmacist involvement were not considered during the study.
During time-period one, baseline information was collected in order to provide a snapshot of patient characteristics of those admitted to the ward. The data collected included demographic information, duration of hospital stay, diagnoses, number of medicines on admission, drug changes during hospital stay and place of residence.
These data were used to identify patient criteria to allow assignment of patients to the most appropriate level of medicines reconciliation during the latter phases of the study.
During time-periods two and three, the time taken for the pharmacy team to complete the medicines reconciliation, time taken to write the discharge summary and time taken to dispense discharge medicines was recorded. During time-period two, these processes were carried out using the normal Trust procedures and all patients received the same level of medicines reconciliation. In time–period three, the new patient criteria were used in order to assign patients to stage 1 or stage 2 medicines reconciliation.
Results
During time-period one, data relating to 98 patients (55 females, 43 males) were collected. The mean age was 65.1 years (range 16–99 years). The majority of patients (89.8%) were taking regular medications and the average number of regular medications taken was 7.4. The most common reason for admission to hospital was infection, which affected 29.6% of the patients studied. Most patients stayed in hospital for less than 48 hours, with only 25.5% staying longer than 48 hours. In the main, changes to admission medications were not made during the patients’ hospital stay, with 65.3% having no change to regular pre-admission medicine regimen except for the addition of new medicines.
Following time-period one data collection, it was agreed by the study team that patients who had no changes to their regular pre-admission medicines during their hospital stay, except for drugs added, would be subject to stage 1 medicines reconciliation by the pharmacist. All other patients would receive stage 2 medicines reconciliation.
During time-period two, the new criterion identified in time-period one was not applied and all patients continued to receive the normal Trust pharmacy service including full medicines reconciliation. A total of 85 patients were studied during this time period. Of these, 60% (n=51) had no changes to their regular medications during hospital stay except for drugs added. The average time taken by the pharmacist to complete the medicines reconciliation process, write the discharge summary and dispense the required discharge medications for these patients was 39.5 minutes (range 18–100 minutes).
During time-period three, those patients who met the new criteria (that is, had no changes to their regular medications during hospital stay except for drugs added) received a modified pharmacy service, in that medicines reconciliation was carried out to stage 1.
A total of 29 patients met the new criteria and received the modified service. The average time taken by the pharmacist to complete the medicines reconciliation process, write the discharge summary and dispense the required discharge medications for these patients was 26 minutes (range 5–42 minutes). The difference in time between time-periods two and three was found to be statistically significant, using student t-test with a time saving of 13.5 minutes between the two groups (p<0.0001).
Conclusions
This study demonstrated that significant time could be saved by the pharmacy team through offering medicines reconciliation at different levels depending on patient need.
Internal Trust data showed that, between March 2009 and February 2010, 5950 patients were admitted to the test ward. This study indicated that approximately 60% of patients could receive stage 1 medicines reconciliation, with an average time saving of 13.5 minutes per patient. The time saved by applying different levels medicines reconciliation to different patient groups depending on need could lead to increases in numbers of patients receiving medicines reconciliation by the pharmacy team.
Ideally, all patients should receive full medicines reconciliation by the pharmacy team; however, given limited pharmacy staff resources, this is not currently feasible. Further work is required to identify other patient characteristics to allow prioritisation of the pharmacy service to those in most clinical need. Improved use of skill mix (for example, use of pharmacy technicians to provide the initial list of medications) and enhanced use of information technology, such as improved access to information held in primary care, may also improve the rates of medicines reconciliation that can be achieved.
Key points
  • Medication errors are a leading cause of patient injury and are especially prevalent at transition points in patient care. Lack of communication at transition points may be responsible for up to 50% of medication errors and up to 20% of adverse drug events in hospital.
  • Within 24 hours of a patient’s admission, it is recommended that hospitals in the UK undertake a process of medicines reconciliation. Ideally, this should be led by a pharmacist.
  • Within Northern Ireland, there are number of practical difficulties with regards to pharmacists conducting full medicines reconciliation within 24 hours including limited pharmacy staff resources and current pharmacy work hours within the region. The study team wished to determine if patient criteria could be identified that would allow medicines reconciliation to be offered at two different levels based on patient need.
  • The majority of patients were discharged from hospital within 48 hours with no changes to their regular, pre-admission medicine regimen except for the addition of new medications. These patients were suitable for stage 1 medicines reconciliation.
  • This study indicated that around 60% of patients could receive stage 1 medicines reconciliation with an average time saving of 13.5 minutes per patient. The time saved by applying different levels medicines reconciliation to different patient groups depending on need could lead to increases in the numbers of patients receiving medicines reconciliation by the pharmacy team.
References
  1. National Prescribing Centre (NPC). Medicines reconciliation: A guide to implementation. www.npc.nhs.uk/improving_safety/medicines_reconciliation/resources/reconciliation_guide.pdf (accessed 18 January 2013).
  2. Campbell C et al. Systematic review of the effectiveness and cost effectiveness of interventions aimed at preventing medication error (medicines reconciliation) at hospital admission;2007. www.nice.org.uk/nicemedia/live/11897/38591/38591.pdf (accessed 18 January 2013).
  3. The Institute for Healthcare Improvement (IHI). How-to Guide: Prevent Adverse Drug Events by Implementing Medication Reconciliation;2011. www.ihi.org (accessed 18 January 2013).
  4. National Institute for Health and Clinical Excellence (NICE) and National Patient Safety Agency (NPSA). Technical patient safety solutions for medicines reconciliation on admission of adults to hospital. 2007. http://guidance.nice.org.uk/PSG001/Guidance/pdf/English (accessed 18 January 2013).


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